The association between diet quality and chrononutritional patterns in young adults

PURPOSE

Young adults eat erratically and later in the day which may impact weight and cardiometabolic health. This cross-sectional study examined relationships between chrononutritional patterns and diet quality in two young adult populations: a university and community sample.

METHODS

Three days of dietary data were collected including food images captured using wearable cameras. Chrononutritional variables were extracted: time of first and last eating occasions, caloric midpoint (time at which 50% of daily energy was consumed), number of eating occasions per day, eating window, day-to-day variability of the above metrics, and evening eating (≥20:00h). The Healthy Eating Index for Australian Adults scored diet quality. Statistical analyses controlled for gender, body mass index, and socio-economic status.

RESULTS

No significant associations between chrononutritional patterns and diet quality were found for all participants (n = 95). However, differences in diet quality were found between university (n = 54) and community (n = 41) samples with average diet quality scores of 59.1 (SD 9.7) and 47.3 (SD 14.4), respectively. Of those who extended eating ≥20:00 h, university participants had better diet quality (62.9±SE 2.5 vs. 44.3±SE 2.3, p < 0.001) and discretionary scores (7.9±SE 0.9 vs. 1.6±SE 0.6, p < 0.001) than community participants. University participants consumed predominately healthful dinners and fruit ≥20:00h whereas community participants consumed predominately discretionary foods.

CONCLUSION

For the general young adult population, meal timing needs to be considered. Food choices made by this cohort may be poorer during evenings when the desire for energy-dense nutrient-poor foods is stronger. However, meal timing may be less relevant for young adults who already engage in healthy dietary patterns.

Iron Content of Wheat and Rice in Australia: A Scoping Review

With a shift towards plant-based diets for human and planetary health, monitoring the mineral content of staple crops is important to ensure population nutrient requirements can be met. This review aimed to explore changes in the iron content of unprocessed wheat and rice in Australia over time. A comprehensive systematic search of four electronic databases and the gray literature was conducted. A total of 25 papers published between 1930 and 2023 that measured the iron content of unprocessed wheat and rice were included. Triticum aestivum was the most common wheat type studied, including 26 cultivars; iron content ranged from 40 to 50 µg/g in the 1930s and 1970s and was more variable after this time due to the introduction of modern cultivars, with most values between 25 and 45 µg/g. The iron content of rice (Oryza sativa) was more consistent at 10-15 µg/g between the 1980s and 2020s. Variations over the years may be attributed to environmental, biological, and methodological factors but these were not well documented across all studies, limiting the interpretation of findings. As the number of individuals following plant-based diets continues to rise, the ongoing monitoring of the mineral content in commonly consumed plant-based foods is warranted.

TRIGLYCERIDE - GLUCOSE INDEX, REMNANT CHOLESTEROL AND COMMON CAROTID ARTERY INTIMA-MEDIA THICKNESS AS AN ATHEROSCLEROTIC MARKER IN ISCHEMIC STROKE PATIENTS

Ischemic stroke (IS) is a major global health concern, often resulting from atherosclerosis and insulin resistance (IR). The triglyceride-glucose index (TyG index), remnant cholesterol (RC), and common artery intima-media thickness (CIMT) are potential markers for assessing atherosclerosis and cardiovascular risk in IS patients. A cross-sectional study was conducted to investigate the association between TyG index, RC, CIMT, and IS in adult patients recruited from a hospital. Demographic, clinical, and laboratory data were collected, and statistical analysis was performed. The study included 50 participants with a balanced gender distribution and a mean age of 57.64 years. Laboratory characteristics showed notable values, and CIMT > 0.6 mm was associated with higher NIH Stroke Scale scores. RC exhibited significant correlations with age, CIMT, lipid profile, and TyG index. The study highlights the potential of TyG index, RC, and CIMT as atherosclerotic markers in IS patients. Favorable prognostic outcomes were observed, emphasizing the importance of early diagnosis and management to improve patient outcomes.

ASSOCIATION OF MPV AND RDW WITH DISEASE ACTIVITY IN PATIENT WITH RHEUMATOID ARTHRITIS

Rheumatoid arthritis (RA) is a chronic autoimmune disorder characterized by inflammation of the synovial joints. Disease activity assessment plays a crucial role in guiding treatment decisions and monitoring disease progression in RA patients. Thus, the current study examines the association between Mean Platelet Volume (MPV), Red Cell Distribution Width (RDW), and disease activity in RA patients. A total of 100 patients were included following the inclusion and exclusion criteria. All participants underwent physical examination and laboratory tests. Disease activity was assessed using the Disease Activity Score 28 (DAS28). The cut-off levels for RDW and MPV were 14.8 and 11.25, respectively. However, a significant association was observed between RDW levels and DAS28, indicating that the group with RDW ≤14.8% displayed higher DAS compared to the RDW >14.8% group. Also, MPV levels did not exhibited statistically significant variations. RDW levels did not show significant disparities among patients with different comorbidities. There is a significant correlation exists between RDW and disease activity in RA exists. Moreover, RDW can be utilized in clinical settings to monitor disease activity effectively. Since RDW is routinely included in standard blood tests, it is cost-effective and more convenient for treating RA cases.

Factor structure of the Oxford Shoulder Score: secondary analyses of the UK FROST and PROFHER trial populations

AIMS

Frozen shoulder and proximal humeral fracture can cause pain, stiffness and loss of function. The impact of these symptoms on patients can be measured using the comprehensively validated, 12-item Oxford Shoulder Score (OSS). Evidence suggests that pain and function may have a differential impact on patients' experience of shoulder conditions, and this may be important for clinical management. We therefore explored the factor structure of the OSS within the UK FROST and PROFHER trial populations.

METHODS

We performed exploratory factor analysis (EFA), followed by confirmatory factor analysis (CFA), on baseline UK FROST data from 490 of the 503 trial participants. Data at 6 months post-randomisation were used for 228 of the 250 participants for the PROFHER trial.

RESULTS

UK FROST factor extraction results, using Velicer's Minimum Average Partial and Horn's Parallel Analysis tests, suggested a unifactorial solution, but two factors were weakly indicated by the less reliable 'Kaiser's eigenvalue > 1' and scree tests. We explored this further using EFA. Eight items (2 to 7, 9 and 10) loaded onto a 'Function' factor, three on a 'Pain' factor (1, 8 and 12) and item 11 cross-loaded. However, one- and two-factor models were rejected in CFA. Factor extraction of PROFHER data at 6 months demonstrated a single first-order factor solution, which was also subsequently rejected in CFA.

CONCLUSION

Insufficient evidence was found, within the constraints of the data available, to support the use of 'Pain' and 'Function' sub-scales of the OSS in either patient population.

Snacking Behaviours of Australian Young Adults: Secondary Analysis of the MYMeals Cross-Sectional Study

Snacking outside main meals may contribute to the high intakes of discretionary foods (i.e., unhealthful foods) among young adults. This study assessed the snacking behaviours of Australian young adults including the contribution of snacking to energy and nutrient intakes, the main foods consumed, and portion sizes. A secondary analysis of the MYMeals study of adults aged 18-30 years who consumed at least one snack food during the recording period (n = 889) was conducted. All food consumed over 3 consecutive days was recorded using a purpose-designed smartphone app. Snack foods contributed 13.2% of energy, 23.4% of total sugars, and 16.2% of saturated fat. Females consumed more energy (13.8% vs. 12.2%, p = 0.007) and total sugars (25.8% vs. 20.8%, p = 0.009), from snacking than males. Fruit (20.2%), chocolate (9.9%), cake-type desserts (8.4%), sweet biscuits (6.1%), and ice-cream-type desserts (5.6%) were the most frequently consumed snacks by young adults. The median portion sizes for the top five snack foods consumed were fruit-106 g (IQR: 73), chocolate-26 g (IQR: 36), cake-95 g (IQR: 88), sweet biscuits-26 g (IQR: 29), and ice cream-75 g (IQR: 42). The current findings may inform population-wide strategies to encourage healthful snacks such as fruit, inform portion control by individuals, and persuade the food industry to reduce the serving size of discretionary snack foods such as cake.

Participant Perceptions in a Long-term Clinical Trial of Autosomal Dominant Polycystic Kidney Disease

Rationale & Objective

The development of new therapies for autosomal dominant polycystic kidney disease requires clinical trials to be conducted efficiently. In this study, the factors affecting the recruitment and retention of participants enrolled in a 3-year randomized controlled trial in autosomal dominant polycystic kidney disease were investigated.

Study Design

Qualitative study.

Setting & Participants

All participants (N=187) were invited to complete a 16-item questionnaire at the final study visit of the primary trial. Participants were recruited to complete a semistructured interview using purposeful sampling according to age, self-reported gender, and randomization group.

Analytical Approach

Descriptive statistics were used for demographic data and questionnaires. The interview transcripts underwent inductive thematic coding.

Results

One hundred and forty-six of the 187 randomized participants (79%) completed the post-trial questionnaire, and 31 of the 187 participants (21%) completed the interview. Most participants (94%) rated their global satisfaction with the trial as high (a score of 8 or more out of 10). Altruism, knowledge gain, and access to new treatments were the main motivators for recruitment. The main reasons for considering leaving the study were concerns about the risk of intervention and family or work issues. Strategies that favored retention included flexibility in attending different study sites, schedule flexibility, staff interactions, and practical support with parking and reminders. The main burden was time away from work with lost wages, and burden associated with magnetic resonance imaging scans and 24-hour urine output collections.

Limitations

The study population was restricted to participants in a single nondrug clinical trial, and the results could be influenced by selection and possible social desirability bias.

Conclusions

Participants reported high levels of satisfaction that occurred as a function of the trial meeting participants' expectations. Furthermore, retention was a balance between the perceived benefits and burden of participation. Consideration of these perspectives in the design of future clinical trials will improve their efficiency and conduct.

Plain-Language Summary

Advances in the clinical practice of autosomal dominant polycystic kidney disease (ADPKD) require affected individuals to voluntarily participate in long-term multicenter randomized controlled trials (RCTs). In this qualitative post hoc study of a 3-year RCT of increased water intake in ADPKD, altruism, knowledge gain, and access to a nondrug treatment positively influenced the decision to volunteer. Ongoing participation was enabled by building flexibility into the study protocol and staff prioritizing a participant's needs during study visits. Although participants completed the required tests, most were considered burdensome. This study highlights the importance of incorporating protocol flexibility into trial design; the preference for interventions with a low risk of adverse effects; and the urgent requirement for robust surrogate noninvasive biomarkers to enable shorter RCTs in ADPKD.

Development and validation of an online tool to assess perceived portion size norms of discretionary foods

BACKGROUND

Perceived portion size norms (typical perception of how much of a given food individuals choose to eat at a single occasion) may have shifted towards larger sizes due to the ubiquity of large serving sizes. However, there is a lack of validated tools to assess such norms for energy-dense and nutrient-poor discretionary foods. This study aimed to develop and validate an online tool to examine the perceived portion size norms of discretionary foods.

METHODS

An online image-series tool of 15 commonly consumed discretionary foods was developed, with eight successive portion size options included for each food. Using a randomised-crossover design, adult consumers (18-65 years) completed the validation study in a laboratory session (April-May 2022) by reporting their perceived portion size norms for each food twice, once based on food images on a computer and another time based on equivalent real food portion size options at food stations in the laboratory. Agreement between methods for each test food was examined using cross-classification and intra-class correlation (ICC).

RESULTS

A sample of 114 subjects were recruited (mean age 24.8 years). Cross-classification indicated >90% of selections were matched in the same or adjacent portion size option. ICC was 0.85 across all foods, demonstrating a good level of agreement.

CONCLUSION

This novel online image-series tool developed to examine perceived portion size norms of discretionary foods showed good agreement with equivalent real food portion size options and may be valuable to investigate perceived portion size norms of common discretionary foods in future studies.

Evidence of low vitamin D intakes in the Australian population points to a need for data-driven nutrition policy for improving population vitamin D status

BACKGROUND

Nearly one in four Australian adults is vitamin D deficient (serum 25-hydroxyvitamin D concentrations [25(OH)D] < 50 nmol L-1 ) and current vitamin D intakes in the Australian population are unknown. Internationally, vitamin D intakes are commonly below recommendations, although estimates generally rely on food composition data that do not include 25(OH)D. We aimed to estimate usual vitamin D intakes in the Australian population.

METHODS

Nationally representative food consumption data were collected for Australians aged ≥ 2 years (n = 12,153) as part of the cross-sectional 2011-2013 Australian Health Survey (AHS). New analytical vitamin D food composition data for vitamin D3 , 25(OH)D3 , vitamin D2 and 25(OH)D2 were mapped to foods and beverages that were commonly consumed by AHS participants. Usual vitamin D intakes (µg day-1 ) by sex and age group were estimated using the National Cancer Institute method.

RESULTS

Assuming a 25(OH)D bioactivity factor of 1, mean daily intakes of vitamin D ranged between 1.84 and 3.25 µg day-1 . Compared to the estimated average requirement of 10 µg day-1 recommended by the Institute of Medicine, more than 95% of people had inadequate vitamin D intakes. We estimated that no participant exceeded the Institute of Medicine's Upper Level of Intake (63-100 µg day-1 , depending on age group).

CONCLUSIONS

Usual vitamin D intakes in Australia are low. This evidence, paired with the high prevalence of vitamin D deficiency in Australia, suggests that data-driven nutrition policy is required to safely increase dietary intakes of vitamin D and improve vitamin D status at the population level.

A review of custom implants for glenoid bone deficiency in reverse shoulder arthroplasty

Reverse Total Shoulder Arthroplasty is being increasingly performed, with indications in both elective and trauma settings. Accordingly, there are an increasing number of revision cases where glenoid bone loss is a concern. There are well recognised surgical techniques for dealing with mild to moderate glenoid wear, including eccentric reaming and impaction grafting. In cases of severe wear or uncontained glenoid defects these may not be suitable, and the surgeon may look to a customised implant to deal with such bone loss. There are several implant manufacturers who currently market and produce patient specific instrumentation and customised glenoid baseplates to achieve the best possible fixation in cases of severe bone loss. This article outlines some examples of custom implants currently available to surgeons, and the process by which they may be procured and used. Implant and surgical considerations, and key aspects of surgical technique are also covered. Literature on outcomes and complications following custom shoulder arthroplasty shows promising results, but at present is limited to relatively small case series with no long-term outcome data.

Haem Iron Intake Is Associated with Increased Major Adverse Cardiovascular Events, All-Cause Mortality, Congestive Cardiac Failure, and Coronary Revascularisation in Older Men: The Concord Health and Ageing in Men Project

BACKGROUND

Nutritional intake can influence major adverse cardiovascular events (MACE). Dietary iron is found in two forms: haem-iron (HI) only found in animal sources and non-haem iron (NHI) present mostly in plant sources.

OBJECTIVE

We evaluated the associations between dietary iron intakes with MACE and iron status biomarkers.

DESIGN

Prospective cohort study.

SETTING

The Concord Health and Ageing in Men Project, Sydney, Australia.

PARTICIPANTS

539 community-dwelling older Australian men aged 75 years and older.

METHODS

Men underwent nutritional assessment using a validated diet history questionnaire. Entries were converted to food groups and nutrients. The dietary calculation was used to derive HI and NHI intakes from total iron intakes. Analyses of iron intakes with iron status biomarkers were conducted using linear regression, and with MACE and individual endpoints were conducted using Cox regression. Five-point MACE comprised of all-cause mortality, myocardial infarction (MI), congestive cardiac failure (CCF), coronary revascularisation, and/or ischaemic stroke. Four-point MACE included the four endpoints of MI, CCF, coronary revascularisation, and/or ischaemic stroke, and excluded all-cause mortality.

RESULTS

At a median of 5.3 (4.6 - 6.3) years follow-up, the incidences were: 31.2% (n = 168) five-point MACE, 17.8% (n = 96) four-point MACE excluding all-cause mortality, 20.1% (n = 111) all-cause mortality, 11.3% (n = 61) CCF, and 3.1% (n = 15) coronary revascularisation. In adjusted analyses, higher HI intake (per 1mg increment) was associated with increased five-point MACE (HR: 1.45 [95% CI: 1.16, 1.80, P = .001]), four-point MACE excluding all-cause mortality (HR: 1.64 [95% CI: 1.26, 2.15, P <.001]), all-cause mortality (HR: 1.51 [95% CI: 1.15, 1.99, P = .003]), CCF (HR: 2.08 [95% CI: 1.45, 2.98, P <.001]), and coronary revascularisation (HR: 1.89 [95% CI: 1.15, 3.10, P = .012]). Compared with the bottom tertile of NHI intake, the middle tertile of NHI intake was associated with reduced risk of all-cause mortality (HR: 0.56 [95% CI: 0.33, 0.96, P = .035]). Total iron intake was not associated with MACE and individual endpoints. Dietary iron intakes were not associated with serum iron and haemoglobin.

CONCLUSION

Higher haem iron intake was independently associated with increased risks of five-point MACE, four-point MACE excluding all-cause mortality, all-cause mortality, CCF, and coronary revascularisation in older men over 5 years.

Macronutrient (im)balance drives energy intake in an obesogenic food environment: An ecological analysis

OBJECTIVE

The protein leverage hypothesis (PLH) postulates that strong regulation of protein intake drives energy overconsumption and obesity when human diets are diluted by fat and carbohydrates. The two predictions of the PLH are that humans (i) regulate intake to maintain protein within a narrow range and that (ii) energy intake is an inverse function of percentage energy from protein because absolute protein intake is maintained within narrow limits.

METHODS

Multidimensional nutritional geometry was used to test the predictions of the PLH using dietary data from the Australian National Nutrition and Physical Activity Survey.

RESULTS

Both predictions of the PLH were confirmed in a population setting: the mean protein intake was 18.4%, and energy intake decreased with increasing energy from protein (L = -0.18, p &lt; 0.0001). It was demonstrated that highly processed discretionary foods are a significant diluent of protein and associated with increased energy but not increased protein intake.

CONCLUSIONS

These results support an integrated ecological and mechanistic explanation for obesity, in which low-protein highly processed foods lead to higher energy intake because of the biological response to macronutrient imbalance driven by a dominant appetite for protein. This study supports a central role for protein in the obesity epidemic, with significant implications for global health.

Wearable Cameras Reveal Large Intra-Individual Variability in Timing of Eating among Young Adults

Studies have shown that young adults follow less structured eating patterns compared with older cohorts. This may have implications for dietary assessment methods which rely on memory and structured meal patterns. Our aim was to describe the intra-individual variation of eating times in young adults aged 18−30 years. Participants (n = 41) wore an Autographer camera that captured first-person perspective images every 30 s for three consecutive days. All images were timestamped and those showing food consumption were used to extract data such as the timing of the first and last eating occasions (EOs), number of EOs per day, and length of eating window. Intra-individual variability was calculated from these data using composite phase deviation (CPD) and coefficient of variation (CV). The number of individuals with high or very high variability was 28 and 18 for timing of first and last EOs, respectively (CPD > 1.70), and 27 and 17 for number of EOs and eating window, respectively (CV > 20%). In this sample of young adults, the lack of regularity in eating patterns should be considered when selecting a dietary assessment method.

A Comparison of the Australian Dietary Guidelines to the NOVA Classification System in Classifying Foods to Predict Energy Intakes and Body Mass Index

NOVA classification distinguishes foods by level of processing, with evidence suggesting that a high intake of ultra-processed foods (UPFs, NOVA category 4) leads to obesity. The Australian Dietary Guidelines, in contrast, discourage excess consumption of “discretionary foods” (DFs), defined according to their composition. Here, we (i) compare the classification of Australian foods under the two systems, (ii) evaluate their performance in predicting energy intakes and body mass index (BMI) in free-living Australians, and (iii) relate these outcomes to the protein leverage hypothesis of obesity. Secondary analysis of the Australian National Nutrition and Physical Activity Survey was conducted. Non-protein energy intake increased by 2.1 MJ (p < 0.001) between lowest and highest tertiles of DF intake, which was significantly higher than UPF (0.6 MJ, p < 0.001). This demonstrates that, for Australia, the DF classification better distinguishes foods associated with high energy intakes than does the NOVA system. BMI was positively associated with both DFs (−1. 0, p = 0.0001) and UPFs (−1.1, p = 0.0001) consumption, with no difference in strength of association. For both classifications, macronutrient and energy intakes conformed closely to the predictions of protein leverage. We account for the similarities and differences in performance of the two systems in an analysis of Australian foods.

Systematic review of the portion size norm of discretionary foods

CONTEXT

Portion size norm is described as the perception of how much of a given food people choose to eat. Reducing the portion size norm of foods that are high in saturated fat, added sugar, and added salt toward smaller sizes might be a potential strategy to promote appropriate portion size selections. However, an overview of existing portion size norms for discretionary foods has yet to be established.

OBJECTIVE

The aim of this systematic review was to examine the portion size norm of discretionary foods and assess the methodologies used to investigate the norm.

DATA SOURCES

The literature search was conducted in 6 databases following the PRISMA guidelines (from inception to January 2022).

DATA EXTRACTION

Forty studies were eligible and grouped into 3 categories by portion size norm measures: normal (n = 26), appropriate (n = 8), and preferred portion sizes (n = 3). Study quality was assessed using the Joanna Briggs Institute Critical Appraisal Tools.

DATA ANALYSIS

A wide range of portion sizes were considered normal for each food type, with means/medians varying from 2- to 4-fold among studies. Studies differed considerably in design, with variables including the setting, food type, food presentation, the manner in which portion-size-related questions were formulated, and the range and number of displayed serving size options. The quality of reviewed studies was mixed (25 studies had low or moderate risk of bias, 15 had high risk of bias), and the method of assessing portion size was not validated in 15 of 33 quantitative studies.

CONCLUSION

The assessment of portion size in future studies should be conducted using tools that are validated for the population of interest so that more definitive conclusions can be drawn regarding portion size norms for discretionary foods.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration number CRD42021249911.

The Contribution of Nutrients of Concern to the Diets of 18-to-30-Year-Old Australians from Food Prepared Outside Home Differs by Food Outlet Types: The MYMeals Cross-Sectional Study

Young adults are frequent consumers of food prepared outside the home (FOH). In a cross-sectional survey, the MYMeals study, we showed FOH provided one-third of meals and snacks for young Australian adults, yet it contributed higher proportions of energy and nutrients of concern, such as saturated fat and sodium. This study aimed to determine the detailed proportional contribution of nutrients of concern from the nine food outlet types captured in the MYMeals study. Young adults residing in New South Wales (NSW), Australia, (n = 1001) used a validated smartphone app to report all types and amounts of food and beverages consumed for three consecutive days, as well as their preparation location. The proportions of daily energy, macronutrients, sodium, total sugars, and saturated fat were calculated for each of the nine following outlet types: bakeries or patisseries, coffee chains, cold-drink chains, fast-food chains, ice creamery or frozen yoghurt outlets, independent cafes or restaurants, pubs (hotels) and clubs, service stations or convenience stores, and others not fitting the above categories. Of all FOH outlet types, independent cafes or restaurants contributed the most energy (17.5%), sodium (20.0%) and saturated fat (17.8%) to the total diet, followed by fast-food chains (12.0% energy, 15.8% sodium, and 12.0% saturated fat) and other outlets, with smaller proportions. For males, the proportion of energy and nutrients contributed by fast-food outlets was higher than for females (14.8% versus 9.8% energy). Menu labelling at independent cafes and restaurants is recommended, comprising, in addition to the energy labels already in use in fast-food restaurants, the labelling of nutrients of concern. The feasibility of this recommendation warrants further exploration.

Vitamin D Fortification of Milk Would Increase Vitamin D Intakes in the Australian Population, but a More Comprehensive Strategy Is Required

Low vitamin D status (serum 25-hydroxyvitamin D (25(OH)D) concentration < 50 nmol/L) is prevalent in Australia, ranging between 15% and 32% in the adolescent and adult populations. Vitamin D intakes are also low across the population and were recently estimated at 1.8−3.2 µg/day on average, assuming equal bioactivity of the D vitamers. In combination, these findings strongly suggest that data-driven nutrition policy is needed to increase vitamin D intake and improve status in the Australian population. Food fortification is a potential strategy. We used up-to-date vitamin D food composition data for vitamin D3, 25(OH)D3, vitamin D2, and 25(OH)D2, and nationally representative food and supplement consumption data from the 2011−2013 Australian Health Survey, to model a fortification scenario of 0.8 µg/100 mL vitamin D for fluid dairy milks and alternatives. Under the modelled fortification scenario, the mean vitamin D intake increased by ~2 µg/day from baseline to 4.9 µg/day from food only (7.2 µg/day including supplements). Almost all individual intakes remained substantially below 10 µg/day, which is the Estimated Average Requirement in North America. In conclusion, this modelling showed that fortification of fluid milks/alternatives with vitamin D at the current permitted level would produce a meaningful increase in vitamin D intake, which could be of potential benefit to those with a low vitamin D status. However, this initial step would be insufficient to ensure that most of the population achieves the North American EAR for vitamin D intake. This approach could be included as an effective component of a more comprehensive strategy that includes vitamin D fortification of a range of foods.

Enhancing Nutrition Care Through Real-Time, Sensor-Based Capture of Eating Occasions: A Scoping Review

As food intake patterns become less structured, different methods of dietary assessment may be required to capture frequently omitted snacks, smaller meals, and the time of day when they are consumed. Incorporating sensors that passively and objectively detect eating behavior may assist in capturing these eating occasions into dietary assessment methods. The aim of this study was to identify and collate sensor-based technologies that are feasible for dietitians to use to assist with performing dietary assessments in real-world practice settings. A scoping review was conducted using the PRISMA extension for scoping reviews (PRISMA-ScR) framework. Studies were included if they were published between January 2016 and December 2021 and evaluated the performance of sensor-based devices for identifying and recording the time of food intake. Devices from included studies were further evaluated against a set of feasibility criteria to determine whether they could potentially be used to assist dietitians in conducting dietary assessments. The feasibility criteria were, in brief, consisting of an accuracy ≥80%; tested in settings where subjects were free to choose their own foods and activities; social acceptability and comfort; a long battery life; and a relatively rapid detection of an eating episode. Fifty-four studies describing 53 unique devices and 4 device combinations worn on the wrist (n = 18), head (n = 16), neck (n = 9), and other locations (n = 14) were included. Whilst none of the devices strictly met all feasibility criteria currently, continuous refinement and testing of device software and hardware are likely given the rapidly changing nature of this emerging field. The main reasons devices failed to meet the feasibility criteria were: an insufficient or lack of reporting on battery life (91%), the use of a limited number of foods and behaviors to evaluate device performance (63%), and the device being socially unacceptable or uncomfortable to wear for long durations (46%). Until sensor-based dietary assessment tools have been designed into more inconspicuous prototypes and are able to detect most food and beverage consumption throughout the day, their use will not be feasible for dietitians in practice settings.

Changes in dietary total and non-haem iron intake is associated with incident frailty in older men: The Concord Health and Ageing in Men Project

Background

Nutritional intake could influence the development of frailty. The aim was to evaluate the associations between dietary iron intakes and changes in dietary iron intakes with frailty.

Methods

Cross-sectional analyses involved 785 men with Fried frailty phenotype (FP) and 758 men with Rockwood frailty index (FI) data aged 75 years and older at nutrition assessment from the Concord Health and Ageing in Men Project prospective cohort study. Of these, 563 men who were FP robust or prefrail, and 432 men who were FI nonfrail were included in the longitudinal analyses for more than 3 years. Dietary intake was assessed at both timepoints using a validated diet history questionnaire. The dietary calculation was used to derive heme iron and nonheme iron intakes from total iron intakes. The associations were evaluated through binary logistic regression.

Results

Incidence of FP frailty was 15.3% (n = 86). In longitudinal analyses, maintaining total iron intakes (medium tertile −2.61–0.81 mg/d), increases in total iron and nonheme iron intakes (high tertiles ≥0.82 mg/d and ≥0.80 mg/d), and changes in nonheme iron intake (1 mg increment) were associated with reduced risks of incident FP frailty (OR: 0.47 [95% confindence interval (CI): 0.24, 0.93, p = .031], OR 0.48 [95% CI: 0.23, 0.99, p = .048], OR 0.41 [95% CI: 0.20, 0.88, p = .022], and OR 0.89 [95% CI: 0.82, 0.98, p = .017]).

Conclusion

Maintaining or increases in total dietary iron and increases or changes in dietary nonheme iron intakes more than 3 years were associated with reduced incidence of FP frailty in older men.

Enablers and barriers of harnessing food waste to address food insecurity: a scoping review

Despite producing sufficient food for the global population, the growing prevalence of food insecurity in developed countries is cause for concern. The millions of metric tons of food wasted each year could be used instead to drastically lower rates of food insecurity and address food sustainability. In this scoping review, we aimed to identify barriers to and enablers of harnessing food waste across food sectors, including food retail, households, and food rescue organizations, to address food insecurity in a developed country, Australia. The findings demonstrate that research on and responsibility for harnessing food waste for food insecurity has predominantly fallen on ill-equipped food rescue organizations. Three primary policy advancements paramount to harnessing food waste to address food insecurity include (1) improving partnerships and subsidies to minimize transportation costs for redistributing imperfect or surplus food from farmers and retailers to those who with food insecurity; (2) enhancing existing partnerships and subsidies to stably involve more nutrition experts in food rescue organizations to improve the quality of foods being redistributed to those facing food insecurity; and (3) initiating interventions and campaigns that combine the following 5 characteristics: free to the participants; address food literacy; use multiple mass-media tools; are age tailored; and frame messages within personal values.

Whole Grain Consumption and Inflammatory Markers: A Systematic Literature Review of Randomized Control Trials

Whole grain foods are rich in nutrients, dietary fibre, a range of antioxidants, and phytochemicals, and may have potential to act in an anti-inflammatory manner, which could help impact chronic disease risk. This systematic literature review aimed to examine the specific effects of whole grains on selected inflammatory markers from human clinical trials in adults. As per the Preferred Reporting Items for Systematic Reviews (PRISMA) protocol, the online databases MEDLINE, Embase, Cochrane, CINAHL, and Scopus were searched from inception through to 31 August 2021. Randomized control trials (RCTs) ≥ 4 weeks in duration, reporting ≥1 of the following: C-reactive protein (CRP), interleukin-6 (IL-6), and tumor necrosis factor (TNF), were included. A total of 31 RCTs were included, of which 16 studies recruited overweight/obese individuals, 12 had pre-existing conditions, two were in a healthy population, and one study included participants with prostate cancer. Of these 31 RCTs, three included studies with two intervention arms. A total of 32 individual studies measured CRP (10/32 were significant), 18 individual studies measured IL-6 (2/18 were significant), and 13 individual studies measured TNF (5/13 were significant). Most often, the overweight/obese population and those with pre-existing conditions showed significant reductions in inflammatory markers, mainly CRP (34% of studies). Overall, consumption of whole grain foods had a significant effect in reducing at least one inflammatory marker as demonstrated in 12/31 RCTs.

Perspective: A Framework for Addressing Dynamic Food Consumption Processes

The study of food consumption, diet, and related concepts is motivated by diverse goals, including understanding why food consumption impacts our health, and why we eat the foods we do. These varied motivations can make it challenging to define and measure consumption, as it can be specified across nearly infinite dimensions-from micronutrients to carbon footprint to food preparation. This challenge is amplified by the dynamic nature of food consumption processes, with the underlying phenomena of interest often based on the nature of repeated interactions with food occurring over time. This complexity underscores a need to not only improve how we measure food consumption but is also a call to support theoreticians in better specifying what, how, and why food consumption occurs as part of processes, as a prerequisite step to rigorous measurement. The purpose of this Perspective article is to offer a framework, the consumption process framework, as a tool that researchers in a theoretician role can use to support these more robust definitions of consumption processes. In doing so, the framework invites theoreticians to be a bridge between practitioners who wish to measure various aspects of food consumption and methodologists who can develop measurement protocols and technologies that can support measurement when consumption processes are clearly defined. In the paper we justify the need for such a framework, introduce the consumption process framework, illustrate the framework via a use case, and discuss existing technologies that enable the use of this framework and, by extension, more rigorous study of consumption. This consumption process framework demonstrates how theoreticians could fundamentally shift how food consumption is defined and measured towards more rigorous study of what, how, and why food is eaten as part of dynamic processes and a deeper understanding of linkages between behavior, food, and health.

Prescribed Water Intake in Autosomal Dominant Polycystic Kidney Disease

Prescribed Water Intake in Autosomal Dominant Polycystic Kidney Disease The effect of increased water intake on kidney cyst growth in patients with polycystic kidney disease was compared for two groups randomly assigned to either prescribed or ad libitum water intake. Over 3 years, there was no difference in height-corrected total kidney volume between the groups.

The Effect of Downsizing Packages of Energy-Dense, Nutrient-Poor Snacks and Drinks on Consumption, Intentions, and Perceptions-A Scoping Review

The single-serve packaging of discretionary foods is becoming increasingly popular, but evidence is limited on whether smaller package sizes can reduce food intake. The aim of this scoping review is to assess the effect of reducing the package size of energy-dense, nutrient-poor (EDNP) snacks and drinks on consumption, intentions, and perception, and to examine the effects of potential moderators or mediators. The search was conducted in six selected databases and grey literature sources, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for the scoping review process (PRISMA-ScR) guidelines. After screening 5562 articles, 30 articles comprising 47 intervention studies were included. Twelve of 15 studies found a significant effect in lowering the actual or intended consumption when a single smaller package was offered compared with a single larger package. When the total serving size was held constant between varying package conditions, such as a multipack, single package, or unpackaged, the results on the actual and intended consumption were inconsistent and varied according to the presence of moderators. Overall, these findings suggest that an overall reduction in the size of a single package is a more promising strategy than providing multipacks to reduce consumption. Changes to the current food environment to promote single smaller packages of EDNP snacks and drinks are necessary to support the better selection of appropriate portion sizes and reduce consumption.

Clinical characteristics and outcomes of hyponatraemia associated with oral water intake in adults: a systematic review

INTRODUCTION

Excessive water intake is rarely associated with life-threatening hyponatraemia. The aim of this study was to determine the clinical characteristics and outcomes of hyponatraemia associated with excess water intake.

METHODS

This review was conducted using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. All studies (case reports, observational or interventional studies) reporting excess water intake and hyponatraemia in adults (1946-2019) were included.

RESULTS

A total of 2970 articles were identified and 177 were included (88.7% case reports), consisting of 590 patients. The mean age was 46±16 years (95% CI 44 to 48 years), 47% female, 52% had a chronic psychiatric disorder and 31% had no underlying condition. The median volume of water consumed and serum sodium at presentation was 8 L/day (95% CI 8.9 to 12.2 L/day) and 118 mmol/L (95% CI 116 to 118 mmol/L), respectively. The motivator for increased water consumption was psychogenic polydipsia (55%); iatrogenic (13%); exercise (12%); habitual/dipsogenic polydipsia (7%) and other reasons (13%). The clinical features on presentation were severe in 53% (seizures, coma); moderate in 35% (confusion, vomiting, agitation) and mild in 5% (dizziness, lethargy, cognitive deficit) and not reported in 5% of studies. Treatment was supportive in 41% of studies (fluid restriction, treatment of the underlying cause, emergency care), and isotonic and hypertonic saline was used in 18% and 28% of cases, respectively. Treatment-related complications included osmotic demyelination (3%) and rhabdomyolysis (7%), and death occurred in 13% of cases.

CONCLUSION

Water intoxication is associated with significant morbidity and mortality and requires daily intake to substantially exceed population-based recommendations. The limitations of this analysis are the low quality and high risk of bias of the included studies.

PROSPERO REGISTRATION NUMBER

A pre-existing protocol in the international prospective register of systematic reviews was updated to incorporate any new amendments and reregistered at http://www.crd.york.ac.uk/PROSPERO (registration no. CRD42019129809).

Using Wearable Cameras to Assess Foods and Beverages Omitted in 24 Hour Dietary Recalls and a Text Entry Food Record App

Technology-enhanced methods of dietary assessment may still face common limitations of self-report. This study aimed to assess foods and beverages omitted when both a 24 h recall and a smartphone app were used to assess dietary intake compared with camera images. For three consecutive days, young adults (18–30 years) wore an Autographer camera that took point-of-view images every 30 seconds. Over the same period, participants reported their diet in the app and completed daily 24 h recalls. Camera images were reviewed for food and beverages, then matched to the items reported in the 24 h recall and app. ANOVA (with post hoc analysis using Tukey Honest Significant Difference) and paired t-test were conducted. Discretionary snacks were frequently omitted by both methods (p < 0.001). Water was omitted more frequently in the app than in the camera images (p < 0.001) and 24 h recall (p < 0.001). Dairy and alternatives (p = 0.001), sugar-based products (p = 0.007), savoury sauces and condiments (p < 0.001), fats and oils (p < 0.001) and alcohol (p = 0.002) were more frequently omitted in the app than in the 24 h recall. The use of traditional self-report methods of assessing diet remains problematic even with the addition of technology and finding new objective methods that are not intrusive and are of low burden to participants remains a challenge.

The Contribution of Foods Prepared Outside the Home to the Diets of 18- to 30-Year-Old Australians: The MYMeals Study

Young adults are the highest consumers of food prepared outside home (FOH) and gain most weight among Australian adults. One strategy to address the obesogenic food environment is menu labelling legislation whereby outlets with >20 stores in one state and >50 Australia-wide must display energy content in kJ. The aim of this study was to assess the contribution of FOH to the energy and macronutrients, saturated fat, total sugars and sodium intakes of young Australians. One thousand and one 18 to 30-year-olds (57% female) residing in Australia’s most populous state recorded all foods and beverages consumed and the location of preparation for three consecutive days using a purpose-designed smartphone application. Group means for the daily consumption of energy, percentage energy (%E) for protein, carbohydrate, total sugars, total and saturated fats, and sodium density (mg/1000 kJ) and proportions of nutrients from FOH from menu labelling and independent outlets were compared. Overall, participants consumed 42.4% of their energy intake from FOH with other nutrients ranging from 39.8% (sugars) to 47.3% (sodium). Independent outlets not required to label menus, contributed a greater percentage of energy (23.6%) than menu labelling outlets (18.7%, p < 0.001). Public health policy responses such as public education campaigns, extended menu labelling, more detailed nutrition information and reformulation targets are suggested to facilitate healthier choices.

Trends in Sales and Industry Perspectives of Package Sizes of Carbonates and Confectionery Products

Discretionary food package sizes are an important environmental cue that can affect the amount of food consumed. The aim of this study was to determine sales trends and reported food industry perspectives for changing food package sizes of carbonates and confectionery between 2005 and 2019. Changes in package sizes of carbonates and confectionery were investigated in Australia, the USA, Canada, and the UK. Sales data (units per capita and compound annual growth rate between 2005 and 2019) were extracted from the Euromonitor database. Qualitative data (market research reports) on industry perspectives on package size changes were extracted from industry and marketing databases. Carbonate sales data showed increased growth of smaller package sizes (<300 mL) and a decrease in sales of larger package sizes (≥2000 mL) in all four countries. In contrast, confectionery sales data showed no consistent trends across the selected countries. No growth was observed for smaller confectionery package sizes but an increase in growth of larger package sizes (50–99 g, >100 g), including share packages, was observed in Australia. Qualitative data (n = 92 articles) revealed key reasons identified by industry for changes in package size related to consumer health awareness, portion size control, convenience, market growth, and government or industry initiatives. Monitoring of discretionary food package sizes provides additional insights into consumers’ food environment.

Longitudinal association of nighttime sleep duration with emotional and behavioral problems in early childhood: results from the Danish Healthy Start Study

STUDY OBJECTIVES

To examine the longitudinal and bidirectional association between nighttime sleep duration and emotional and behavioral problems (EBPs) over 15 months among preschool children.

METHODS

Data of children aged 2 to 6 years from the control group of the Danish Healthy Start Study, a 15-month obesity prevention intervention, were used. Nighttime sleep duration was measured using a 7-day sleep record. EBPs were assessed by the Strengths and Difficulties Questionnaire Total Difficulties (SDQ-TD) score and Prosocial Behavior (SDQ-PSB) score. Multivariable regression models were conducted to examine the bidirectional associations between changes in nighttime sleep duration and SDQ scores.

RESULTS

With adjustment for child, family factors, and parental stress level, every hour extra nighttime sleep at baseline was associated with a 1.02 decrease in SDQ-TD score and 77% lower odds of having an abnormal SDQ-TD score (≥90th percentile) at the follow-up (p = 0.01). Children who increased their nighttime sleep duration over the 15-month demonstrated a similar concurrent reduction in SDQ-TD score (β = -1.28, p = 0.02) compared with those who decreased or had no change in nighttime sleep duration. After additional adjustment for sleep problem and habit variables, the significant associations remained. No associations were found between nighttime sleep duration and SDQ-PSB scores. Examination of SDQ scores as predictors of subsequent changes in nighttime sleep duration showed no significant associations.

CONCLUSIONS

Among preschool children, longer nighttime sleep duration was associated with a decline in EBPs, but not vice versa. Our study provides new longitudinal evidence to support sleep interventions to improve EBPs in early childhood.Clinical trials: The Healthy Start Study: https://clinicaltrials.gov/ct2/show/NCT01583335Trial registration: ID NCT01583335.

Early enteral feeding is beneficial for patients after pelvic exenteration surgery: A randomized controlled trial

BACKGROUND

Postoperative feeding practices vary after pelvic exenteration surgery because of the lack of nutrition research in this specific surgical area. Postoperative ileus (POI) is common after pelvic exenteration surgery, and early enteral feeding is often avoided because of the lack of evidence and the belief that this may induce POI in this patient cohort. The aim of this study was to determine the effects of early enteral feeding after pelvic exenteration surgery on return of bowel movement and POI.

METHODS

A randomized controlled trial was conducted with patients undergoing pelvic exenteration surgery from November 2018 to June 2020. Forty participants received standard nutrition care (parenteral nutrition) and 47 participants received trophic enteral feeding (20 ml/h) via a nasogastric tube, in addition to standard care, until participants were upgraded to free fluids. Time to first bowel movement and rates of POI were the main outcome measures.

RESULTS

There was no significant difference between arms for time to first bowel movement; however, POI rates were significantly less in participants who were enterally fed (P = .036) in the per-protocol analysis. Regressions showed that the longer patients were restricted from an oral diet after surgery, the greater the time was to first bowel movement and the greater the postoperative complication rates (P < .0005).

CONCLUSIONS

Early enteral feeding can be commenced safely to improve gastrointestinal function after pelvic exenteration surgery.

Vitamin D composition of Australian foods

Australia needs accurate vitamin D food composition data to support public health initiatives. Previously, limitations in analytical methodology have precluded development of a comprehensive database. We used liquid chromatography with triple quadrupole mass spectrometry (LC-QQQ) to analyse 149 composite samples representing 98 foods (primary samples n = 896) in duplicate for vitamin D₃, 25-hydroxyvitamin D₃ (25(OH)D₃), vitamin D₂, 25(OH)D₂. The greatest concentrations of vitamin D₃ were found in canned salmon and a malted chocolate drink powder (fortified); chicken eggs and chicken leg meat contained the most 25(OH)D₃. Margarine (fortified) and chocolate contained the greatest concentrations of vitamin D₂, with smaller amounts found in various meat products. 25(OH)D₂ was detected in various foods, including meats, and was quantitated in lamb liver. These data advance knowledge of dietary vitamin D in Australia and highlight the importance of analysis of these four forms of vitamin D to accurately represent the vitamin D content of food.

Preoperative nutritional status impacts clinical outcome and hospital length of stay in pelvic exenteration patients - a retrospective study

BACKGROUND

Preoperative malnutrition is common in surgical oncology patients and can have negative effects on postoperative outcomes. Pelvic exenteration is major surgery associated with high morbidity rates. Associations between preoperative malnutrition, determined using the patient-generated subjective global assessment, and postoperative outcomes in this patient cohort has not yet been investigated.

AIM

To determine if preoperative nutritional status is associated with postoperative surgical and quality of life (QoL) outcomes after pelvic exenteration surgery.

METHODS

A retrospective cohort study was conducted at a quaternary hospital investigating 123 patients who had pelvic exenteration surgery from January 2017 to August 2019. Preoperative nutritional status and postoperative surgical and QoL outcomes were collected and analysed to determine any associations.

RESULTS

Overall, 49.6% of patients were female with a median age of 59 years. Forty patients (32.5%) were malnourished and 83 (67.5%) were well nourished before surgery. Well-nourished patients had a shorter length of hospital stay (p = 0.034) and at 6 months post-surgery, presented with a significantly better physical and mental QoL score (p = 0.038 and p = 0.001 respectively). The regression analyses showed that intensive care unit (ICU) readmission rates were 7.19 times more likely to occur in malnourished patients (p = 0.022).

CONCLUSIONS

Preoperative malnutrition is associated with increased length of stay, ICU readmissions and poorer QoL following pelvic exenteration. Nutrition screening, assessment and optimisation of management are essential in this patient cohort to improve patient outcomes. Future studies are needed to measure the effect of interventions and identify the most beneficial model of care for this complex patient group.

National survey of occupational advice for lower limb arthroplasty patients

BACKGROUND

Little is known what advice or support patients are given about return to work (RTW) after hip or knee replacement surgery.

AIMS

This study aims to understand the delivery, timing and content of 'RTW' advice currently delivered by surgical teams offering hip and knee replacements across the UK.

METHODS

National online survey exploring five specific areas relating to 'RTW' advice: (i) timings of interactions between hospital orthopaedic teams and patients prior to surgery, (ii) routine delivery of 'RTW' advice, (iii) methods used to deliver 'RTW' advice, (iv) confidence delivering advice and (v) need for an occupational 'RTW' advice intervention.

RESULTS

A total of 152 participants including surgeons, physiotherapists, occupational therapists and nurses from 59 different public and private health providers responded. Only 20% (n = 30) of respondents reported that working patients were identified as a specific subgroup in need of additional support. Overall, 62% (n = 92) stated that they did not routinely offer 'RTW' advice. When given, 'RTW' advice was almost always verbal, generic advice using blanket timescales and based on the respondent's anecdotal experience rather than the patients individualized needs. Overall, 116 (78%) felt an occupational advice intervention was needed.

CONCLUSIONS

This national survey demonstrated wide variation in the timing, content and delivery of information and advice for patients in work and intending to RTW after hip and knee replacement surgery. Current RTW advice provided to hip and knee replacement patients is inadequate.

Dietary exposures in childhood and adulthood and cardiometabolic outcomes: a systematic scoping review

Associations between diet and cardiometabolic outcomes are often based on a single measurement of diet in adulthood. Dietary exposures in childhood are thought to influence cardiometabolic disease development and individuals' diets can change over time, therefore dietary exposure in childhood and over long periods are both important to consider. This scoping review aimed to identify and characterise the literature on associations between diet measured in both childhood and adulthood and cardiometabolic outcomes. Seven databases were searched; eligible evidence sources were original analyses published as a journal article in English. Exposures included measures of dietary intake, diet quality and eating behaviours measured in both childhood and adulthood with at least five years between first and last measurements. Cardiometabolic outcomes included measures of anthropometry, biochemistry, vascular structure/function and disease states/scores. We identified 37 eligible articles from nine cohort studies. Dietary exposures were measured between two and eight times and most often assessed by food frequency questionnaire or diet history. The dietary exposures most frequently examined were protein, fat, carbohydrate, fruit, vegetables, sugar-sweetened beverages and breakfast. Cardiometabolic outcomes were predominantly based on risk markers. Authors utilised a variety of analytical approaches to transform and analyse repeated measures of diet, providing insights relevant to different lifespan nutrition concepts. The literature on associations between diet in childhood and adulthood and cardiometabolic outcomes is limited, but such studies have great potential to extend our knowledge in ways only possible with repeated measures of diet over time. Further research is needed to develop the evidence base for diet-disease relationships from a life course perspective, accounting for diet in both childhood and adulthood.

Dietary Behaviors That Place Young Adults at Risk for Future Osteoporosis

Dietary behaviors during adolescence and emerging adulthood have important consequences for peak bone mass (PBM) attainment. This study aimed to examine dietary factors that are either beneficial or detrimental to bone health and determine the major sources of calcium in the diets of a sample of young adults. A cross-sectional survey was conducted among 189 Australians aged 18–30 years. Three-day dietary intakes were collected using consecutive 24 h recall interviews. Daily totals for energy and nutrients and serves for food groups were computed. The proportion contribution of calcium (mg) from different food groups as well as calcium (mg) per portion and per 100 g were calculated. Females and males failed to meet the recommendations for dairy (91%, 82%), fruit (89%, 94%) and vegetables (74%, 86%). Eighty percent were above the recommended daily intake range for sodium. For calcium, 53% of females and 48% of males had intakes below the estimated average requirement (EAR). Milk products and dishes made the highest mean calcium contribution per portion (mg) mean standard deviation (SD), 204 mg (212) and accounted for 30% of calcium intake in females and 35% in males. As young adulthood is the final chance for dietary manipulation before PBM is achieved, these dietary risk factors should be addressed.

Breakfast size is associated with daily energy intake and diet quality

OBJECTIVES

The aim of this study was to investigate the role of breakfast consumption and breakfast size on daily energy, nutrient intakes, and diet quality.

METHODS

One-day 24-h recall data from the 2011 to 2012 National Nutrition and Physical Activity Survey (n = 9341, adults ≥ 19 y) were analyzed, and respondents were classified into breakfast consumers or skippers. Breakfast consumers were further classified into quartile of breakfast size (energy intake [EI] from breakfast × 100%/daily EI). Diet quality was assessed using the Healthy Eating Index for Australian Adults. General linear modeling was undertaken to compare groups, adjusting for potential confounders.

RESULTS

Overall, 85.9% of adults consumed breakfast, contributing a mean of 19.9 ± 10.9% of daily EI for consumers. Among breakfast consumers, obtaining a higher proportion of daily EI from breakfast was associated with lower daily intakes of energy, added sugars, saturated fat, and alcohol (%E); higher intakes of dietary fiber (%E) and most micronutrients (per 1000 kJ); and better Healthy Eating Index for Australian Adults scores (P_trend < 0.0001). Additionally, those in the highest quartile of breakfast size (>25.5% EI) had higher diet quality scores (P < 0.001) but similar daily EI (P = 0.751) compared with breakfast skippers.

CONCLUSIONS

These findings indicate that obtaining a higher proportion of daily EI from breakfast may result in more favorable dietary profiles and lower daily EI. Further research is needed to confirm this.

The use of a patch to augment rotator cuff surgery - A survey of UK shoulder and elbow surgeons

Background

Rotator cuff tears are a common cause of shoulder pain and can result in prolonged periods of pain, disability and absence from work. Rotator cuff repair surgery is increasingly used in an attempt to resolve symptoms but has failure rates of around 40%. There is a pressing need to improve the outcome of rotator cuff repairs. Patch augmentation increasingly being used within the NHS in an attempt to reduce repair failures. The aim of this survey was to determine current UK practice and opinion relating to the factors that influence choice of patch, current patient selection and willingness to assist with generation of improved evidence.

Methods

An online survey was sent to the surgeon members of the British Elbow and Shoulder Society (BESS). Questions covered respondent demographics, experience with patches, indications for patch augmentation and willingness to be involved in a randomised trial of patch augmented rotator cuff surgery.

Results

The response rate was 105/550 (19%). 58% of respondents had used a patch to augment rotator cuff surgery. 70% of patch users had undertaken an augmented repair within the last 6 months. A wide surgical experience in augmentation was reported (ranging 1 to 200 implants used). However, most surgeons reported low volume usage, with a median of 5 rotator cuff augmentation procedures performed. At least 10 different products had been used. Most of the patches used were constructed from human decellularised dermis tissue, although porcine derived and synthetic based patches had also been used. Only 3–5% stated they would undertake an augmented repair for small tears across ages, whereas 28–40% and 19–59% would do so for large or massive tears respectively. When assessing patient suitability, patient age seemed relevant only for those with large and massive tears. Half of the surgeons reported an interest in taking part in a randomised controlled trial (RCT) evaluating the role of patch augmentation for rotator cuff surgery, with a further 22% of respondent’s undecided.

Conclusions

A variety of patches have been used by surgeons to augment rotator cuff repair with a wide range of operator experience. There was substantial uncertainty about which patch to use and differing views on which patients were most suitable. There is a clear need for robust clinical evaluation and further research in this area.

Is Preoperative Sarcopenia a Good Predictor of Postoperative Complications and Outcomes after Pelvic Exenteration Surgery?

Background: Sarcopenia is common in oncology patients and has been found to be associated with poorer outcomes after surgery. Pelvic exenteration is a major surgery associated with high rates of morbidity. The aim of this study was to determine if preoperative sarcopenia is associated with postoperative complications and outcomes after pelvic exenteration surgery. Methods: A retrospective study was conducted including 64 oncology patients who had undergone pelvic exenteration surgery between August 2015 and January 2018 and had available preoperative lumbar CT images. Skeletal muscle index (SMI) was calculated by analysing CT images using body composition software. Sarcopenia was determined by using previously published SMI sex-specific cut-offs. Preoperative nutritional status, nutritional indicators and other clinical factors were also collected. Results: There was no association between preoperative sarcopenia and outcomes after pelvic exenteration surgery, however, increased weight (p=0.027) and BMI (p=0.025) were associated with a greater number of total complications. Increasing age was also significant (p=0.001) in explaining the greater number of complications. Greater complexity of surgery itself was associated with greater postoperative complications (p=0.014) and increased length of hospital stay (p=0.001). Conclusion: Preoperative sarcopenia, using dichotomous cut-off points, is not sensitive enough to predict postoperative complications and outcomes in oncology patients undergoing pelvic exenteration surgery; however, other preoperative factors such as weight, BMI and age, and the complexity of surgery, do affect outcomes. Assessment tools that incorporate several clinical and physical factors, such as frailty assessments, should be used in future studies to identify risk factors in such major surgeries.

Bridging the gap between research and practice for nutrition support after pelvic exenteration surgery

BACKGROUND AND OBJECTIVES

Current best practice for postoperative feeding in surgical patients is well established, however implementation of evidence-based practice comes with many challenges. A common barrier is surgeon adherence to guidelines and the reasons behind this are not well understood. Pelvic exenteration surgery is a complex surgery and postoperative feeding methods in this patient cohort vary significantly from patient to patient. The aim of this study was to identify barriers and enablers for surgeons to implement evidence based feeding methods after pelvic exenteration surgery and provide practical strategies for non-surgeon healthcare workers to improve compliance.

METHODS AND STUDY DESIGN

A qualitative study was conducted by performing semi-structured interviews with 12 Consultant Surgeons at hospitals in Australia and New Zealand with dedicated pelvic exenteration services. Deductive and inductive thematic analysis was performed in line with the Theoretical Domains Framework and Behaviour Change Wheel model to identify relevant domains, themes and intervention functions.

RESULTS

Culture was identified as an overarching theme that influenced postoperative feeding practices, surgeon behaviours and sub-themes. Identified sub-themes included motivation, relationships and expectations, environment and 'moving forward'. Motivations to use different types of feeding routes postoperatively varied across hospitals. Relationships, surgeons' expectations and the environment all influenced the way in which patients were fed postoperatively. Practical strategies were identified to assist non-surgeon healthcare workers achieve positive change moving forward with postoperative feeding.

CONCLUSIONS

Practical strategies to promote enablers and reduce barriers are required to bring about positive change and align practice with the evidence.

Ultra-processed food consumption drives excessive free sugar intake among all age groups in Australia

OBJECTIVE

To analyze the contribution of ultra-processed foods to the intake of free sugars among different age groups in Australia.

METHODS

Dietary intakes of 12,153 participants from the National Nutrition and Physical Activity Survey (2011-12) aged 2+ years were evaluated. Food items collected through two 24-h recalls were classified according to the NOVA system. The contribution of each NOVA food group and their subgroups to total energy intake was determined by age group. Mean free sugar content in diet fractions made up exclusively of ultra-processed foods, or of processed foods, or of a combination of un/minimally processed foods and culinary ingredients (which includes table sugar and honey) were compared. Across quintiles of the energy contribution of ultra-processed foods, differences in the intake of free sugars, as well as in the prevalence of excessive free sugar intake (≥ 10% of total energy) were examined.

RESULTS

Ultra-processed foods had the highest energy contribution among children, adolescents and adults in Australia, with older children and adolescents the highest consumers (53.1% and 54.3% of total energy, respectively). The diet fraction restricted to ultra-processed items contained significantly more free sugars than the two other diet fractions. Among all age groups, a positive and statistically significant linear association was found between quintiles of ultra-processed food consumption and both the average intake of free sugars and the prevalence of excessive free sugar intake.

CONCLUSION

Ultra-processed food consumption drives excessive free sugar intake among all age groups in Australia.

The Impact of Preoperative Immunonutrition and Standard Polymeric Supplements on Patient Outcomes After Pelvic Exenteration Surgery, Taking Compliance Into Consideration: A Randomized Controlled Trial

BACKGROUND

The effect of immunonutrition vs standard polymeric nutrition in the preoperative phase on patient outcomes is still unclear, which could be due to contributing factors such as poorly reported compliance and unequal provision of protein, energy, and volume. The aim of this study was to examine the effects of preoperative immunonutrition compared with standard polymeric supplements matched for energy, protein, volume, length of stay, and postoperative complications in pelvic exenteration surgery, taking into consideration compliance.

METHODS

This was a single-blinded, randomized, controlled trial in patients undergoing pelvic exenteration surgery. Fifty-two participants were randomly assigned to consume 3 immunonutrition supplements/d for 5 days preoperatively, and 56 participants were randomly assigned to consume 3 standard polymeric supplements/d for 5 days preoperatively. Primary and secondary outcome measures were assessed. Compliance with each nutrition regime was recorded during the intervention, and subanalysis was conducted.

RESULTS

There was no significant difference between immunonutrition and standard polymeric supplements on length of stay (P = 0.988) or postoperative complications (P = 0.179) after pelvic exenteration surgery. Compliance with nutrition supplements was significantly less in malnourished (n = 33) compared with well-nourished participants (n = 74) (P = 0.016). Compliance varied between study groups, although not significant.

CONCLUSION

Preoperative immunonutrition did not significantly impact length of stay or postoperative complications compared with standard polymeric supplements after pelvic exenteration surgery, despite controlling for protein, energy, and volume. Compliance, protein, and energy may considerably impact the effect of immunonutrition, particularly in malnourished patients.

Impact of a national enhanced recovery after surgery programme on patient outcomes of primary total knee replacement: an interrupted time series analysis from "The National Joint Registry of England, Wales, Northern Ireland and the Isle of Man"

OBJECTIVE

We aimed to test whether a national Enhanced Recovery After Surgery (ERAS) Programme in total knee replacement (TKR) had an impact on patient outcomes.

DESIGN

Natural-experiment (April 2008-December 2016). Interrupted time-series regression assessed impact on trends before-during-after ERAS implementation.

SETTING

Primary operations from the UK National Joint Registry (NJR) were linked with Hospital Episode Statistics (HES) data which contains inpatient episodes undertaken in National Health Service (NHS) trusts in England, and Patient Reported Outcome Measures (PROMs).

PARTICIPANTS

Patients undergoing primary planned TKR aged ≥18 years.

INTERVENTION

ERAS implementation (April 2009-March 2011).

OUTCOMES

Regression coefficients of monthly means of Length of stay (LOS), bed day costs, change in Oxford knee scores (OKS) 6-months after surgery, complications (at 6 months), and rates of revision surgeries (at 5 years).

RESULTS

486,579 primary TKRs were identified. Overall LOS and bed-day costs decreased from 5.8 days to 3.7 and from £7607 to £5276, from April 2008 to December 2016. Oxford knee score (OKS) change improved from 15.1 points in April 2008 to 17.1 points in December 2016. Complications decreased from 4.1 % in April 2008 to 1.7 % in March 2016. 5-year revision rates remained stable at 4.8 per 1000 implants years in April 2008 and December 2011. After ERAS, declining trends in LOS and bed costs slowed down; OKS improved, complications remained stable, and revisions slightly increased.

CONCLUSIONS

Different secular trends in outcomes for patients having TKR have been observed over the last decade. Although patient outcomes are better than a decade ago ERAS did not improve them at national level.

Ultra-processed foods and recommended intake levels of nutrients linked to non-communicable diseases in Australia: evidence from a nationally representative cross-sectional study

OBJECTIVE

This study aimed to describe the consumption of ultra-processed foods in Australia and its association with the intake of nutrients linked to non-communicable diseases (NCDs).

DESIGN

Cross-sectional study.

SETTING

National Nutrition and Physical Activity Survey (2011-2012).

PARTICIPANTS

12,153 participants aged 2+ years.

MAIN OUTCOME MEASURES

Average dietary content of nutrients linked to NCDs and the prevalence of intake outside levels recommended for the prevention of NCDs.

DATA ANALYSIS

Food items were classified according to the NOVA system, a classification based on the nature, extent and purpose of industrial food processing. The contribution of each NOVA food group and their subgroups to total energy intake was calculated. Mean nutrient content of ultra-processed food and non-ultra-processed food fractions of the diet were compared. Across quintiles of the energy contribution of ultra-processed foods, differences in the intake of nutrients linked to NCDs as well as in the prevalence of intakes outside levels recommended for the prevention of NCDs were examined.

RESULTS

Ultra-processed foods had the highest dietary contribution (42.0% of energy intake), followed by unprocessed or minimally processed foods (35.4%), processed foods (15.8%) and processed culinary ingredients (6.8%). A positive and statistically significant linear trend was found between quintiles of ultra-processed food consumption and intake levels of free sugars (standardised β 0.43, p<0.001); total (β 0.08, p<0.001), saturated (β 0.18, p<0.001) and trans fats (β 0.10, p<0.001); sodium (β 0.21, p<0.001) and diet energy density (β 0.41, p<0.001), while an inverse relationship was observed for dietary fibre (β -0.21, p<0.001) and potassium (β -0.27, p<0.001). The prevalence of non-recommended intake levels of all studied nutrients increased linearly across quintiles of ultra-processed food intake, notably from 22% to 82% for free sugars, from 6% to 11% for trans fat and from 2% to 25% for dietary energy density, from the lowest to the highest ultra-processed food quintile.

CONCLUSION

The high energy contribution of ultra-processed foods impacted negatively on the intake of non-ultra-processed foods and on all nutrients linked to NCDs in Australia. Decreasing the dietary share of ultra-processed foods would substantially improve the diet quality in the country and help the population achieve recommendations on critical nutrients linked to NCDs.

Percutaneous fixation with Kirschner wires versus volar locking-plate fixation in adults with dorsally displaced fracture of distal radius: five-year follow-up of a randomized controlled trial

Aims

The aim of this study was to compare the clinical effectiveness of Kirschner wire (K-wire) fixation with locking-plate fixation for patients with a dorsally displaced fracture of the distal radius in the five years after injury.

Patients and Methods

We report the five-year follow-up of a multicentre, two-arm, parallel-group randomized controlled trial. A total of 461 adults with a dorsally displaced fracture of the distal radius within 3 cm of the radiocarpal joint that required surgical fixation were recruited from 18 trauma centres in the United Kingdom. Patients were excluded if the surface of the wrist joint was so badly displaced it required open reduction. In all, 448 patients were randomized to receive either K-wire fixation or locking-plate fixation. In the K-wire group, there were 179 female and 38 male patients with a mean age of 59.1 years (19 to 89). In the locking-plate group, there were 194 female and 37 male patients with a mean age of 58.3 years (20 to 89). The primary outcome measure was the patient-rated wrist evaluation (PRWE). Secondary outcomes were health-related quality of life using the EuroQol five-dimension three-level (EQ-5D-3L) assessment, and further surgery related to the index fracture.

Results

At 12 months, 402/448 participants (90%) recruited into the main study provided PRWE scores. At year two, 294 participants (66%) provided scores; at year five, 198 participants (44%) provided scores. There was no clinically relevant difference in the PRWE at any point during the five-year follow-up; at five years, the PRWE score was 8.3 (12.5) in the wire group and 11.3 (15.6) in the plate group (95% confidence interval -6.99 to 0.99; p = 0.139). Nor was there a clinically relevant difference in health-related quality of life. Only three participants had further surgery in the five years after their injury (one in the wire group and two in the plate group).

Conclusion

This follow-up study continues to show no evidence of a difference in wrist pain, wrist function, or quality of life for patients treated with wires versus locking plates in the five years following a dorsally displaced fracture of the distal radius.

Cite this article: Bone Joint J 2019;101-B:978–983.

Scoping review: Diagnosis and management of periprosthetic joint infection in elbow arthroplasty

BACKGROUND

Total elbow arthroplasty is an effective treatment for patients with painful elbow arthritis. Infection can be a serious complication. The aim of this scoping review was to document the available evidence on periprosthetic elbow infection.

METHODS

A search of Medline, Embase and PubMed was performed; two authors screened results independently. Systematic reviews, randomised controlled trials, cohort studies, case-control studies and case series including periprosthetic elbow infection were eligible.

RESULTS

A total of 46 studies were included. The median rate of periprosthetic elbow infection reported from recent published studies is 3.3%. The most commonly identified causative organisms are Staphylococcus aureus and Staphylococcus epidermidis. Risk factors include younger age, rheumatoid arthritis, obesity, previous surgery or infection to the elbow, and postoperative wound complications. Debridement, antibiotics and implant retention results in implant survival rates of 50-90%. Two-stage revision results in improved functional outcome scores, but with recurrent infection rates of 12-28%.

CONCLUSIONS

Total elbow arthroplasty carries a higher risk of infection when compared to other major joint replacements. The current body of literature is limited and is almost exclusively low volume retrospective case series. The best management of periprosthetic elbow infection is difficult to determine, but two-stage revision appears to be the gold standard.

Physiotherapy for primary frozen shoulder in secondary care: Developing and implementing stand-alone and post operative protocols for UK FROST and inferences for wider practice

OBJECTIVES

The United Kingdom Frozen Shoulder Trial (UK FROST) compares stand-alone physiotherapy and two operative procedures, both with post operative rehabilitation, for primary frozen shoulder in secondary care. We developed physiotherapy protocols for UK FROST, incorporating best evidence but recognizing uncertainty and allowing flexibility.

METHODS

We screened a UK Department of Health systematic review and UK evidence-based guidelines (Hanchard et al., 2012; Maund et al., 2012) for recommendations, and previous surveys of UK physiotherapists (Hanchard et al., 2011, 2013) for strong consensus. We conducted a two-stage, questionnaire-based, modified Delphi survey of shoulder specialist physiotherapists in the UK National Health Service. This required positive, negative or neutral ratings of possible interventions in four clinical contexts (stand-alone physiotherapy for, respectively, predominantly painful and predominantly stiff frozen shoulder; and post operative physiotherapy for, respectively, predominantly painful and predominantly stiff frozen shoulder). We proposed respectively mandating or recommending interventions with 100% and 90% positive consensus, and respectively disallowing or discouraging interventions with 90% and 80% negative consensus. Other interventions would be optional.

RESULTS

The systematic review and guideline recommended including steroid injection and manual mobilizations in non-operative care, and we mandated these for stand-alone physiotherapy. Consensus in the pre-existing surveys strongly favoured advice, education and home exercises, which we mandated across contexts. The Delphi survey led to recommendation of some supervised exercise modalities, plus the disallowing or discouragement-in various contexts-of immobilization and some 'higher-tech' electrotherapies and alternative therapies.

CONCLUSIONS

We developed physiotherapy protocols despite incomplete empirical evidence. Their clear structure enabled implementation in data-sheets designed to facilitate recording, monitoring of fidelity and reporting of interventions. Other trials involving physiotherapy may benefit from this approach.